0:01

Let's look at this case of a

0:02

patient's status post-trauma.

0:05

So in this individual, we see that there

0:09

is a large subdural hematoma on the left

0:14

side with hyperdense acute blood products.

0:19

But not only that, there are areas in which there are

0:22

low-density areas surrounded by the hyperdense areas.

0:28

This—

0:29

low density that is within the hyperdense area

0:34

in the subdural hematoma—is

0:36

what is known as the swirl sign.

0:39

The swirl sign, S-W-I-R-L, implies active bleeding.

0:44

So remember that for the blood products

0:47

to be bright, it has to be clotting.

0:49

But if you have active hemorrhage of

0:52

oxyhemoglobin—but coming into a subdural hematoma

0:57

that has partially clotted—

0:58

it will look like this low-density

1:01

area, the so-called swirl sign.

1:03

So this implies active bleeding, and therefore,

1:09

either you're going to recommend that neurosurgical

1:12

intervention occurs earlier or that there be

1:16

short-term follow-up to make sure that this

1:19

subdural hematoma does not continue to grow

1:22

and grow and grow and lead to herniation.

1:25

When we look at this patient and we try to

1:28

evaluate for mass effect or herniation, we

1:32

usually go to the level of the septum pellucidum.

1:35

So what we do is we take a measuring marker, and we go

1:39

from the midline falx down to the midline falx there.

1:46

And then we measure from that midline to the

1:49

septum pellucidum, and we see that it represents 4.5

1:54

millimeters of midline shift from left to right.

1:58

So this is an important factor because, depending

2:01

upon the degree of midline shift, it may push the

2:04

neurosurgeons to intervene more rapidly when there

2:09

is greater than five millimeters of midline shift.

2:13

So in this case, we have a subdural hematoma

2:16

which shows a swirl sign of active bleeding.

2:19

In addition, you notice that there's hemorrhage

2:22

in the medial occipital lobe and that

2:25

there's hemorrhage along the midline here.

2:30

With a patient who has a chronic subdural,

2:33

this is the same patient as the last

2:35

patient, and you notice that that subdural

2:38

hematoma has grown on the left side

2:41

because it is actively bleeding.

2:44

So we've gone from a patient who had a

2:46

small subdural and no midline shift to a

2:50

patient who has active bleeding in a much

2:53

larger subdural hematoma and midline shift.

2:57

When looking at subdural hematomas, it's important

3:00

to measure the width of the subdural hematoma.

3:03

So once again, because one of the criteria

3:05

for intervention is the width of a subdural,

3:09

you want to measure it

3:10

completely. In this case, 12.2 millimeters,

3:16

left-side subdural hematoma with

3:19

4.5 millimeters of left-to-right shift.

Case: SDH with Active Bleeding

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